Painful intercourse after menopause has solutions

by Tara Haelle
 

Virginia Madsen remembers when she had to explain to her friends what a period was. The Academy Award–nominated actress from Chicago who turned 52 this past September, and decades after that earlier experience, she has found herself explaining something else that’s pretty common among women.

“Now that this generation is entering menopause, it’s kind of the same thing,” she says. “There’s not a lot in the mainstream media about it, which is why women are not talking about it.” Madsen is referring to post-menopausal dyspareunia, or painful sex. Madsen is spokesperson for a campaign about dyspareunia, “Finding the Words,” sponsored by Shionogi, a Japanese company that manufactures an oral treatment for dyspareunia approved by the US Food and Drug Administration in February 2013.

Dyspareunia affects up to 45 percent of women after menopause, according to the North American Menopause Society (NAMS). Jen Gunter, an independent OB/GYN who specializes in painful intercourse, said the number would probably be higher if all women wanting to have sex were evaluated. “Many women don’t seek care about the condition, and many have partners who are unable to have sex (erectile dysfunction) or no longer have partners,” she says.

NAMS published a position statement in the September issue of Menopause about diagnosis and treatment of vulvovaginal atrophy, the underlying condition that causes dyspareunia. The statement notes that vulvovaginal atrophy is likely underdiagnosed — which other research supports — and can significantly impair a woman’s quality of life.

Vaginal atrophy is a thinning of the vaginal wall once estrogen production drops at menopause. Before menopause, estrogen keeps the vaginal walls plush and stretchy, but during menopause, estrogen production in women actually drops below that of men, says Dr. Ricki Pollycove, an OB/GYN who specializes in menopause at California Pacific Medical Center in San Francisco and is the medical spokeswoman for the Shionogi-sponsored campaign.

“The vagina makes its own nice cream so you can have a fairly friction-free environment for intercourse,” says Pollycove. “The low friction protects your tissue from too much chafing and accomplishes pleasurable intercourse.”

Although vaginal atrophy doesn’t happen right away, it has often set in by the fourth or fifth year of menopause in women not taking hormone replacement therapy. “Women can have all those classic menopausal symptoms in the beginning and not have this,” Pollycove says. “It takes longer for the tissues to shrink, lose collagen, lose thickness and elastic fibers and those nice rugal folds that allow the vagina to stretch under pressure.”

Once those biological changes do happen, however, the effects on a woman’s sex life can be significant.

“If you live a long, healthy life, guess what — you get to be in menopause and you’re going to be in menopause for many, many years to come because we’re living so much longer,” Madsen says. “If your sex life is interrupted or taken away from you for this reason, it can be debilitating. It can wreak havoc on your relationship. That’s a terrible loss for most people.”

Yet she and Pollycove both noted that women tend to be reluctant about bringing up the issue, often even dismissing it or blaming themselves for not getting turned on. In a nationwide survey of women suffering from vulvovaginal atrophy, only 56 percent had discussed their symptoms with a healthcare provider. Most didn’t even know that the cause of their vaginal dryness, painful intercourse, or general irritation was related to menopause: Only 24 percent attributed their symptoms to menopause, and only 12 percent thought it was due to hormonal changes.

Worse, though? Only 7 percent of women reported that their own healthcare providers had initiated a conversation about vulvovaginal atrophy. The breakdown in communication flows both directions.

It’s a sad commentary that Miley Cyrus’s twerking on primetime television can dominate national discourse for a week, yet discussions about older women and their sex lives can be considered taboo at worst and distasteful at best. Sure, there’s the pop culture idea of sexy cougars hooking up with young men, but millions of ordinary women in their 50s, 60s, 70s, and older have sex, too, and would like to continue. Madsen wants women to know that often, the pain of post-menopausal sex is treatable.

“Women tend to take care of everyone else first before ourselves,” Madsen says. “When we start going into menopause — an area we already aren’t talking enough about — and then add to that something to do with your sexual health, people are just shying away from talking about it and not realizing it’s a physical problem.”

According to the NAMS statement on vulvovaginal atrophy management, the therapy used should depend on how severe a woman’s symptoms are, her own preferences, and the safety and effectiveness profile of the treatment for each patient.

Gunter says over-the-counter lubricants can work for some women. “We recommend silicone-based lubricants typically for post-menopausal tissue as the paraben and glycerin that are found in many gel- and water-based lubes can be irritating for many women,” Gunter says. “Many also don’t use enough or don’t reapply during sex. I always recommend a liberal trial of lube first, especially if the atrophy is only causing symptoms during sexual activity.”

If these lubricants do not alleviate the problem, first-line therapy for mild to moderate symptoms is the use of topical vaginal estrogen when vulvovaginal atrophy is the only symptom of menopause, sometimes even if a woman is on hormone-replacement therapy (HRT). “Systemic HRT isn’t always enough to treat the vagina in the doses used, so it needs to be individualized,” Gunter says. “Some women will also need vaginal estrogen.”

Vaginal estrogen is typically a localized cream or suppository. “Low-dose vaginal estrogen is considered to have a lower risk profile compared with commonly used doses of systemic estrogen therapy because it produces very low serum levels,” according to the NAMS statement. The main side effects of vaginal estrogen therapy listed in the statement are yeast infections, vaginal bleeding, and breast pain, and Gunter points out that decades of data support the safety of vaginal estrogen.

The NAMS statement lists estrogen therapy as the most effective treatment for moderate to severe symptoms. The recently approved oral therapy available is the non-hormonal ospemifene. But ospemifene [brand name Osphena, manufactured by Shionogi] has not been directly compared in head-to-head studies with estrogen therapy. It also contains a black box warning for bleeding and thrombosis (blood clots).

The NAMS statement notes that long-term studies about the safety of local estrogen and ospemifene on women’s endometrial tissues are still needed. In addition, “there are insufficient data to confirm the safety of local estrogen in women with breast cancer,” the statement notes. The most commonly reported side effect from ospemifene, the oral treatment, were hot flashes, which occurred among 7 percent of women taking the medication, compared to 2 percent taking a placebo in one study.

Gunter notes that ospemifene has been around a lot less time than topical treatments and therefore has been studied less. “Osphena increases the risk of clots; vaginal estrogen is unlikely to do that,” Gunter says. “Osphena stimulates the endometrium; vaginal estrogen will not. Osphena has not been proven to be safer for women with breast cancer. Vaginal estrogen also reduces the risk of urinary tract infections; we don’t know if Osphena does that.”

Regardless of the treatment options women seek, women should speak up about their symptoms. “If you have pain with sex and your doctor can’t give you a diagnosis and offer treatment, ask for a referral to someone else,” Gunter says. “Pain with sex isn’t normal and almost always can be treated. For women who have lost their libido after menopause and have pain with sex, treating atrophy often restores libido.”

Pollycove says that women need to pay attention to all domains of their lives to achieve high quality of life. “I think it is so fundamental that women undervalue pleasure as part of the sexuality we have the opportunity to enjoy,” she says. “If women put the effort into their sexuality that they put into their dermatology and their skin and face, they would have great love lives.”